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and organisational g v
Human Factors in Incident Investigation –p practical tools & techniques q
Ronny Lardner AFIChemE F Founder d & Registered R i t d Psychologist P h l i t The Keil Centre Ltd ronny@keilcentre com au
[email protected]
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Agenda • Common shortcomings in oil & • • • • • • •
gas industry incident investigations Development & application of Human Factors Analysis Tools The importance of interview skills R l ti Relationship hi to t improving i i safety, and other aspects of performance? An oil & gas industry case study Alignment with “just and fair culture” Questions & discussion Further reading & resources
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What do we mean by ‘human factors’ in hazardous industries? and organisational g v UK HSE “top-ten” human factors issues Managing human failure Procedures Training T i i and d competence Staffing, including supervision Organisational change
Safety Safety-critical critical communication Human factors in design Fatigue & shiftwork Organisational (safety) culture Maintenance, inspection and testing
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GOAL: Managing human reliability & f il failure Influences on human reliability & performance Organisational (safety) culture Usable procedures
Safety-critical communication
Training and competence
Human factors in design
Staffing levels, including supervision
Fatigue & shiftwork
Organisational change
Maintenance, inspection and testing
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Background • Major j oil and g gas company p y • Good quality technical analysis, l i poor on b behaviour h i / cultural aspects
• Tended to focus on blame, and assume all unsafe acts are intentional
• Desire to improve p
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Human Factors Analysis Tools Gather Evidence
Assemble Timeline
Traditional analysis
Identify Critical Factors & Causes; Write recommendations CF 1
CF 2
Specify behaviour(s) to be understood Human factors analysis
Intentional
ABC Analysis
Behaviour intentional or unintentional?
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Unintentional
Human Error Analysis
CF 3
Human Factors Analysis Tools Gather Evidence
Assemble Timeline
Traditional analysis
Identify Critical Factors & Causes; Write recommendations CF 1
CF 2
Specify behaviour(s) to be understood Human factors analysis
Intentional
ABC Analysis
Behaviour intentional or unintentional?
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Unintentional
Human Error Analysis
CF 3
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Human error analysis Oil and gas industry case study
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HFAT analysis of five isolation incidents • Three Th human h errors, two t
violations of the control of work / isolation procedures. • One O incident i id t iinvolved l d a very experienced electrical technician – a classic maintenance i t error • The investigations identified a number of performanceshaping h i ffactors, t which hi h increased the likelihood of errors • Control of work system was analysed to establish if it was “error-tolerant” © The Keil Centre
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Human Factors Analysis Tools Gather Evidence
Assemble Timeline
Traditional analysis
Identify Critical Factors & Causes; Write recommendations CF 1
CF 2
Specify behaviour(s) to be understood Human factors analysis
Intentional
ABC Analysis
Behaviour intentional or unintentional?
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Unintentional
Human Error Analysis
CF 3
How people process information 2 1
Memory of Memory of training training, procedures, recent events, etc
Perceive Perceive information from outside world 3
Make decision decision based on perceptions and d information from memory
Decision Perception
Action 4
Take action actionbased based on decision
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Memory
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Organisational v
Performance Shaping Factors
Type of Factor
Example
The task
Workload – rushing to finish a job
Communications
Poor handwriting
Procedures & documentation
Ambiguous wording
Environment
High background noise
g & experience p Training
New start
Human-Machine Interaction
Alarm flood
Personal
Recent bereavement
Social & team
Personality clash © The Keil Centre
Your Example
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Human reliability assessment - a proactive technique for f critical tasks -
Task
Probability of failure
Task of similar nature to process isolation, with some independent checking of output
?? in 1000
Above, without independent checking of output
?? in 1000
Above, plus time shortage for Above error detection and correction
?? in 1000
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Human reliability estimate*
Task
Probability of failure
Task of similar nature to process isolation, with some independent checking of output
3 in 1000
Above, without independent checking of output
9 in 1000
Above, plus time shortage for Above error detection and correction
81 in 1000
Minimum platform error rate = 22 in 1000
Performanceshaping factors
*older people are less reliable on perceptual tasks (e.g. reading P&ID diagrams or small print on labels). © The Keil Centre
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Recommendations • Reducingg isolation error rate • Early detection of isolation errors • Educate personnel on human error, and performance-shaping ffactors t • Share learning with other platforms, and other organizations using g same control of work software • Reducing isolation violations
• Result: 66% reduction in errors, and remaining errors are of lower potential consequence
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Safety culture and human factors
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Strong safet safety c culture: lt re Cannot eliminate error; ATC = 98% error; 2% intentional
• Key points
Decreasing D i number of unsafe acts
Many process industries need more management focus, tools & techniques for identif ing and red identifying reducing cing error, and performanceshaping factors Human error includes management error More traditional behavioural safety wont help
Maturing safety culture
Strong Link to Just & Fair Culture
Weak safety culture: Error obscured by focus on more obvious violations, and blame
A developing safety culture: 55% violations; 45% error Capability improvement po e e t needed here?
Intentional Unintentional (Violation) (Error)
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Top-ten tips • • • • • • • • • •
Choose a well-researched human factors analysis tool Carefullyy select those who yyou train to use this tool Include interviewing skills in the training Brief senior managers and workforce on potential benefits Define type(s) of incidents where human factors analysis is mandatory, and where it is optional I l d ah Include human ffactors t skillset kill t iin th the iinvestigation ti ti tteam Ensure a clear distinction is made between intentional and unintentional behaviours Ensure the investigation and analysis uncovers what influenced unsafe behaviour, or made error more likely Give your analysts coaching and feedback to keep skills fresh Publicise success © The Keil Centre
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Further reading 1 • General reading about human performance and failure
E Error and d performance-shaping f h i ffactors t – Safety at the Sharp End: A guide to non-technical skills, by Rhona Flin and colleagues. Published by Ashgate (2008). $29.00 on Amazon
Intentional behaviour / violations – Bringing out the Best in People, by Aubrey Daniels. Published by McGraw-Hill (2000). $17.00 on Amazon. Short book on ABC analysis, not specifically about safety. – The Psychology of Safety Handbook, by Scott Geller. Published by CRC Press (2000). $147.00 on Amazon. Longer book specifically about safety.
• Energy Institute guidance on investigating and analysing human and organisational factors aspects of incidents and accidents
http://tinyurl com/brswynv http://tinyurl.com/brswynv
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Further reading 2 • Human Failure Types
http://tinyurl com/d5ou9y7 http://tinyurl.com/d5ou9y7
• Interviewing
Investigative Interviewing: Psychology and Practice, by Rebecca Milne and Ray Bull. P bli h d b Published by Wiley Wil (1999). (1999) $56.00 $56 00 on A Amazon. Thi This is i an iinteresting t ti read d ffor th those who h want to know some theory and practice on this subject. Investigative Interviewing Explained, by Brian Ord and colleagues. Published by LexisNexis/Butterworths (2008). $86.00 on Amazon.
• Human Factors Analysis Tools
A paper published in Process Safety and Environmental Protection - the official journal of the European Federation of Chemical Engineering - which describes methods which have been successfully used to enhance incident investigations, and develop better recommendations to address violations, errors. http://tinyurl.com/cy4cavj
• Human Factors Analysis Tools case study – reducing isolation errors
http://tinyurl.com/c2aadaw
• Just and Fair Culture Model
http://tinyurl.com/c65nuol
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